NHCW 2016: Providing Wraparound Care for Complex Needs

Monday, August 08, 2016

Tyrone Rucker is all about integration. As Central City Concern’s Integrated Health and Recovery Treatment (IHART) program case manager, he is the glue for the team that provides integrated services to about 250 CCC patients. “I love to see people’s faces when I explain IHART to them,” Tyrone says. “There’s a whole team here to help you.”

In 2014, CCC received a behavioral health integration grant from Health Resources and Services Administration (HRSA) to develop a health home model for patients with co-occurring severe mental illness and complex medical needs, blending evidence–based models of care from both primary care and mental health.

Since 2014, the IHART program has provided wraparound mental and physical health care services for patients experiencing severe mental illness and addictions as well as medical issues. The interdisciplinary team has 14 members, including psychiatric providers, mental health and substance use disorder counselors, nurses, peers, case managers, and care coordinators

“I like the team approach,” Tyrone says, “we all get the same information.” On a daily basis, Tyrone has contact with seven to 10 patients. The team makes sure patients have the mental and physical health care they need, as well as other services.

IHART patients receive their primary care at the Old Town Clinic, a patient-centered medical home recognized by both the state of Oregon and the federal government for excellence in care and co-located with the Old Town Recovery Center, where IHART is housed. People placed in the IHART program are dealing with co-occurring severe mental illness and complex medical needs. They need wraparound care to help them achieve basic needs.


Sixty-eight percent of people with a mental illness have one or more chronic physical conditions, often related to their psychiatric medications or conditions, including obesity, high blood pressure and high blood sugar. If not monitored closely these can lead to heart disease, type 2 diabetes and early death.

Every morning, the IHART team has a 30-minute huddle to discuss patient needs that include housing, cell phones, glasses, bus passes and food boxes. They need reminders about dental appointments, lab tests and medication. “We get to treat the whole person,” Tyrone says. “Everything is on site.”

Tyrone feels that everyone on the team is treated equally. “I have a voice,” he says, when talking about providing care. He also believes the team has a special internal integration as well. “We support each other and cover for each other,” he says. Tyrone is a single father and studying for his bachelor’s degree in health care administration. He likes how his work family helps him when times get stressful. “They take care of me.”


The IHART team is seeing positive results. Ninety-two percent of IHART patients kept suggested primary care appointments compared with 75 percent of similar patients who are not enrolled with an integrated team. And 56 percent of IHART patients had the recommended annual screenings for high blood pressure, diabetes, cholesterol levels and body mass index, compared with 24 percent of similar patients. Strong engagement with primary care and completion of recommended screenings can lead to improved health outcomes over time.

IHART has a maximum caseload of 300 people, but CCC leadership intends to continue developing this innovative and successful model. And after working with the IHART team since the beginning, Tyrone believes the integrated approach is the very best way to provide outstanding health care for CCC patients. He says, “I really appreciate all the medical care teams that help integration to succeed.”

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